Knowledge, practice and associated factors towards intravenous cannula-related infection prevention among nurses working at Northwest Amhara Regional State Comprehensive Specialized Hospitals, Ethiopia

Background Intravenous cannula-related infections are one of the leading causes of healthcare-associated infections. It leads to morbidity and mortality in hospitalized patients. Nurses play a significant role in the prevention of these infections. Whereas in Ethiopia, there is limited information and published studies done on nurses’ knowledge, practice, and associated factors and also most of other available studies done only the magnitude it lack associated factors. The purpose of this study was to assess nurses’ knowledge, practice, and associated factors toward intravenous cannula-related infection prevention. Methods An institution-based cross-sectional study was conducted at Northwest Amhara Regional State Comprehensive Specialized Hospitals on May 1-30/2022. By using single population proportion formula the sample size was determined; we used a 50% proportion value (0.05), and 95% Confidence Interval 5% margin of error. A simple random sampling method was used to select 423 nurses. The data were collected by using structured pretested self-administered questionnaires. Then coded, and enter into epi-data version 4.6 and exported into the statistical package for social science version 23 for cleaning and analyzing the data. Data were presented by texts, tables, and figures. A binary logistic regression model was used to assess the association between variables. Based on the adjusted odds ratio, variables having a p-value less than 0.05 with a 95% confidence interval were used to state associated with the outcome variables. Results A total of 412 nurses participated in this study with 97.4% response rate. The participants had good knowledge and practice in proportions of (54. 9%) and (53. 4%) respectively. Being male, working wards/units, having training, and a higher educational level were factors that were significantly associated to having good knowledge. Working wards/units, having good knowledge, training, and access to guidelines were significantly associated with performing good practice. Conclusion The finding of this study revealed that nearly half of the nurses had poor knowledge and practice in intravenous cannula-related infection prevention. As a result, hospital administrators and other concerned stakeholders better to prepare and ensure that guidelines are available, provide training, and develop the educational levels of nurses.


Background
An intravenous (IV) cannula is an invasive procedure performed on hospitalized patients to administer drugs, fluids, and nutrients, and also take a blood sample intravenously either centrally or peripherally [1,2].More than 90% of hospital-admitted patients take IV medications [3].However, it has its own complication such as phlebitis, pain, sepsis, venous thrombosis, hemorrhage, and infiltration [4][5][6][7].These complications are mostly occurred due to poor healthcare practices during insertion, maintenance, and removal of the intravenous cannula [8][9][10].Around 98.8% of intravenous cannularelated infections are preventable by nurses [11].Even if Central Disease Control (CDC) develops a guideline for the prevention of infection related to IV cannula [12].Still, the problem is a major public health problem, and it affects the health of the patient, and the quality of health care [13].
In the world, according to the International Nosocomial Infection Control Consortium (INICC) report around 1,789 patients develop intravenous cannularelated infections among 743,508 patients having IV cannula [14].Its mortality rate increased by 18.9% & length of hospital stay by 6.46% [15].In the United States of America, around 153 patients develop intravenous cannula-related infections among 85,063 patients having IV cannula each year [16].It increased the death rate by 3%, lengths of stay in hospital by 2%, and also hospitalization costs by $3,886 [13].In Southwest Asia, due to poor nursing care, seven times increase the incidence of intravenous cannula-related infection [17].In Africa, around 40% of patients develop an intravenous cannula-related infection.It affects the health of the patient, increase length of hospital stay, and health care costs [14,18].Different studies showed that in Ethiopia around 84% and 61.1% of intravenous cannula-related infections are occurred due to poor nursing care practice [19,20].
In the healthcare setting, more than 71% of intravenous cannulas were inserted and cared for by nurses [21].Therefore, nurses play a significant role in the prevention of intravenous cannula-related infections.By applying intervention strategies like frequently assessing and monitoring the venous cannula site, preparing necessary equipment, selecting appropriate anatomical insertion sites, and also keeping sterility technics during insertion, medication administration, and removal [22,23].To perform those tasks and provide the patient highquality care, it needs good knowledge and practice.[24].Although studies showed that below half of the nurses had good knowledge and practice for instance in Egypt, 50.6%, 7.4% Nepal, 49.1%, 33.9%, and India, 35%, 33%, knowledge, and practice respectively [25][26][27].
Factors such as educational status, work experience, training towards intravenous cannula-related infection prevention, sex, and age of nurses were contributing factors to the nurse's knowledge and practice towards intravenous cannula-related infection prevention [26][27][28][29][30].
Continuous quality improvements programs like education, training, and adherence to standardized guidelines towards intravenous cannula-related infection preventions are possible solutions to reduce IV cannula related infections.They increase the nurses' knowledge, practices and also reduced the incidence of infection rate [31][32][33][34].
Most of the studies done only the magnitude of nurses' knowledge and practice but, this study includes the factors that affect the nurse's knowledge, and practice [3,[35][36][37][38][39].And also in Ethiopia, there is limited information and published studies done on nurses' knowledge, practice, and associated factors toward IV cannula-related infection prevention.Therefore, the aim of this study conducted to assess the nurse's Knowledge, Practices, and associated factors regarding intravenous cannularelated infection prevention among nurses working at Northwest Amhara Regional State Comprehensive Specialized Hospital, Northwest Ethiopia.

Study setting
The study was conducted in Northwest Amhara Regional State Comprehensive Specialized Hospitals.
It is situated in Ethiopia's northwest region.There are 5 comprehensive specialty hospitals.1,756 nurses are found.Those are Debre Markos comprehensive specialized hospital is found in East Gojjam Zone Debre Markos town, which is located 300 km away from Addis Ababa, North West Ethiopia, and 265 km from Bihar Dar, the capital city of Amhara regional state.Tibebe Gione and Felege Hiwote Comprehensive Specialized Hospitals are found in Bahir Dar city, which is located 565 km away from Addis Ababa, University of Gondar Comprehensive Specialized Hospital is found in the Gondar town, which is located Northwest direction of Ethiopia, 727 km away from Addis Ababa, and 175 km from Bahir Dar, Debre Tabor Comprehensive Specialized Hospital is found in South Gondar 667 km away from Addis Ababa, and 102 km away from Bahir Dar.

Study design and period
An institutional-based cross-sectional study was conducted from May 01-30/2022.

Source and study populations
All nurses who were working at Northwest Amhara Regional State Comprehensive Specialized Hospitals were the source population and those nurses who were available during the data collection period were the study population.

Study unit
Individual nurses who are randomly selected were our study unit

Eligibility criteria
All nurses who were working in Northwest Amhara Regional State Comprehensive Specialized Hospitals, Northwest Ethiopia, available during the data collection period were included in the study.

Sample size determination
The sample size was calculated by using the single population proportion formula: n = (Zα/ 2 ) 2 p (1-p)/d 2 from the formula n: denotes sample size, Z: value of standard normal distribution at 95% CI (Z =1.96), (Z α/2 ) 2 = 3.84 P: is the proportion in the previous study but there was no previous study done in Ethiopia among staff nurses using p-value 50%= 0.

Sampling procedures
Among one thousand seven hundred fifty six (1,756) nurses four hundred twenty three (423) nurses were selected by using simple random sampling method.Participants proportionally allocate by using proportional allocation formula from all Northwest Amhara Regional State-Comprehensive Specialized Hospitals.And also again it was proportionally allocated based on there working units/wards of each hospital.Finally, by using a simple random sampling (lottery method), the participants were selected from each study unit/ward (Fig. 1).

Good knowledge
Participants were considered to have a good knowledge if they score the median score or above, on the knowledge questions of IV cannula-related infection prevention

Poor knowledge
Participants were considered to have a poor knowledge if they score below the median score, on the knowledge questions of IV cannula-related infection prevention.

Nurse to patient ratio/day
Normal standard nurse to patient ratios per day are as follows: Ward nurses: 1:5, Emergency nurses: 1:3, Intensive Care Unit nurses: 1:1.
To say having worked over load nurses provide patient care more than the normal standard/ day.

Good practice
Participants were considered have a good practice if they score the median score or above, on the practice questions of IV cannula-related infection prevention.

Poor practice
Participants were considered to have a poor practice if they score below the median score, on the practice questions of IV cannula-related infection prevention.

Data collection tool and procedure
Self-administered close-ended questionnaires were used to collect the data related to the knowledge and practice of nurses on IV cannula-related infection prevention; the tool has four parts, which include socio-demographic characteristics, institutional, work, and other related factors.The questionnaires were adopted from published studies and guidelines [12,29,40].The data was collected from all Amhara regional state comprehensive specialized hospital by 5 trained BSCnurses for data collector, and 5 trained MSCnurses for supervisor.Upon the data collection, the data collector provides appropriate information about the study to the participants and instructs them to full-fill the questionnaire independently to maintain the transmission of information between the participants and also informed that their names, and personal identity were not mentioned and confidentiality is kept to respond to honest responses.Then informed consent was obtained to assure their willingness to participate in this study.

Data quality control and management
The questionnaire was pre-tested two weeks before the actual data collection period on 22 (5%) nurses in Dessie Comprehensive Specialized Hospital.The reliability of the tool was tested by Cronbach's Alpha test the value was 0.812 and 0.804 for knowledge and practice respectively, and also the validity of the tool was tested by the face validity method.The principal investigator provided one day's training for data collectors and supervisors about the objectives of the study, questionnaire, data collection procedure, and also the rights of the participants three days before the actual day of the data collection period.All data were checked for completeness and consistency on the data collection day, before data entry and during analysis.

Data processing and analysis
The collected data were first checked manually by the supervisor and principal investigator for completeness and consistency during the data collection period and rechecked before data entry.Then, coded, and enter into the Epi-data version 4.6 and exported into the Statistical Package for Social Science (SPSS) version 23 for cleaning the data and analysis.Descriptive statics such as central tendency, frequency, and percentage were presented by texts, tables, and figures.Model fitness was checked by using the Hosmer-Lemeshow goodness of fit test its value was 0.867 and 0.352 for knowledge and practice respectively.Multicollinearity was cheeked by using the variance inflation factor (VIF) its value 1.025-1.99,and 0.526-0.976,1.026-1.99,and tolerance its value 0.526-0.964for knowledge, and practice respectively.A binary logistic regression model was used to see the association between dependent and independent variables.Due to the limited number of independent variables, we did not choose the variables by using bivariable analysis.All independent variables were directly entered into multivariable analysis, adjusted odds ratios were calculated, and variables with a p-value of 0.05 or less at a 95% confidence interval were deemed significant to the outcome variables.

Socio demographic characteristic of nurses
From a total of 423 nurses, 412 nurses participated in this study with a response rate of 97.4%.Among the total participants, half (208 (50.5%)) were male.The median age of the respondents was 30 years with a standard deviation (±5.368), and the minimum and maximum ages of the respondent were 22 and 56 respectively.Most of the participants 345(83.7%)have a bachelor's degree and also two-third (274(66.7%)) of participants were married (Table 1).

Institutional, work and other related factors on prevention IV cannula-related infection
One-third (137 (33.3%)) of participants reported that there is availability of guidelines in the hospital.More than two-thirds (298(72.3%)) of participants are having work overload.Among the participants, 112(27.2%)are working in the surgical ward, more than half (240 (58.3%)) of participants read guidelines for IV cannularelated infection prevention, one-fourth (104 (25.2%)) of nurses were trained on IV cannula-related infection prevention.More than one-third (152(36.9%)) of the participant were 6-9 years' of work experience (Table 2).

Nurses' practice towards prevention of IV cannula-related infection
The result of this study revealed that 221(53.6%),95% CI (48.8, 58.7) of the respondents had good practice of intravenous cannula related infection prevention (Table 4).

Factors associated with nurses' knowledge towards IV cannula-related infection prevention
Variables that were ≤ 0.05 p-value with 95% CI were significantly associated with the outcome variable.
According to this analysis had taken training, working ward/unit, sex, and educational level BSc degree and above were significantly associated with the knowledge of nurses.

Factors associated with nurses' practice towards IV cannula-related infection prevention
Variables that were ≤ 0.05 p-value with 95% CI were significantly associated with the outcome variable.According to this analysis having good knowledge, having taken training, availability of guidelines, and working wards/ units were significantly associated with the practice of nurses.Nurses who have good knowledge were 2.55 times more likely to perform good practice towards IV cannula-related infection prevention as compared to nurses who do not have good knowledge [AOR = 2.55, 95% CI (1.67, 3.89)].Nurses who had taken training were 2.12 times more likely good practice towards IV cannula-related infection prevention as compared to nurses

Discussion
Intravenous cannula-related infections are the most common healthcare-acquired infection.It occurs mostly by poor healthcare practices [10].The finding of this study showed that 54.9 % with a 95% CI (50.2, 59.5) of the study participants had good knowledge of intravenous cannula-related infection prevention.This finding is in line with a study conducted in Egypt that showed that 50.6% of nurses had good knowledge of IV cannula-related infection prevention [25].Whereas this finding is higher than studies conducted in India 35% [27], and Yemen 21% [41].This inconsistency might be due to sociodemographic differences [42], and the differences in results scoring those studies; the knowledge was scored as good, moderate, and poor in this study scored as good and poor knowledge and also in Yemen, there is sociopolitically instability (war) due to this nurses might not upgrade their educational level, the findings indicate that more than half of the study participants held nursing diplomas, and there is a correlation between educational status and level of knowledge.Additionally, the timing of the Indian study differs from the current one by five years it might be due to the time difference develop technology for instance accessibility of the internet nurse's motivation to read related books and guidelines, and the participants were chosen using a consecutive sampling technique, whereas in this study using simple random sampling technique, However, the result of this study was lower than the studies conducted in China, 83.5% [31], Nepal, 82.4% [35], and Malaysia,75.9%[36].This inconsistency might be due to differences in the study setting; the study was conducted in Nepal and Malaysia in a single hospital, and in China ninety-one hospitals, whereas in this study the study was conducted in five hospitals, and also the difference might be due study units; in those studies participates were selected only in inpatient ward nurses whereas this study includes nurses working in all wards/units, and also the difference might be due to sampling technique the study done in Nepal census method of sampling technique was used whereas in this study simple random sampling technique was used and also the difference might be due to training the study showed that in Chain, around half of the nurses were trained towards IV cannula-related infection prevention whereas, in this study only twenty-five percent of nurses were trained.Nurses who received training increase their knowledge and practice on intravenous cannula-related infection prevention [32].
In multivariable logistic regression analysis, variables that were significantly associated with the knowledge of nurses towards IV cannula-related infection prevention were sex, educational level, training, and working wards/ units.Nurses who had taken training were more likely knowledgeable as compared to nurses who had not trained.This finding is supported by studies conducted in Nepal, China, and Asia [26,30,37].This could be updating the knowledge of nurses could have better knowledge they would easily understand basic principles and standards of practice and also motivates them to further read related books/literature [32,43].Being male nurses more likely knowledgeable about IV cannula-related infection prevention as compared to female nurses.This finding is supported by the study conducted in India [27].The possible explanation for this finding might be the educational status of nurses in this study the majority of the master's nurses were male nurses and diploma nurses were female nurses.The result showed that participants who had master's nurses are more likely to have better knowledge than diploma nurses, this result might be mostly out-of-work females who spend their time in home-based activities for instance; food preparation, child and homebased sanitation.Therefore, may not get time to upgrade their educational levels [44].
Nurses who have masters and bachelor's degrees were more likely knowledgeable about IV cannula-related infection prevention as compared to nurses who had diploma nurses.This finding is supported by the studies conducted in Malaysia and Iraq [29,45].This may be because nurses with higher education levels have acquired important knowledge, which has encouraged them to participate in courses on IV cannula-related infection prevention, directly or indirectly.
Nurses who worked in surgical, Pediatrics, and NICU were more likely knowledgeable on IV cannula-related infection prevention as compared to nurses who worked in the outpatient department.The possible justification for this might be the procedure is routinely performed in those wards/units; Nurses might be motivated to familiarize themselves with IV cannula-related infection prevention by reading related books and reviewing related literatures.The result of this study showed that in those wards/units, more than fifty percent of nurses read guidelines /review-related literatures whereas only seventeen percent of nurses working in OPD read guidelines /review-related literatures.Literature support that it is a positive relationship between knowledge and reading practice [43].
The finding of this study showed that 53.6% with a 95% CI [48.8, 58.7] of the study participants had good practices in intravenous cannula-related infection prevention.which is in line with a study conducted in Egypt which is 53.3% [38].While this finding is higher than the studies conducted in India 33%, and Nepal 33.9% [26,39].The difference could be due to the difference in study designs those studies were done observational whereas this study was done by self-report, and the time of study those studies were done 5 and 3 years before this study.It might be due to time differences develop technology for instance   accessibility of the internet is high nurses motivate to read related books/guidelines.However, this study was lower than studies conducted in Malaysia which is 83.7% [36], and India which is 68% [45].This difference might be due to socio-demographic differences, and also in an Indian study due to training the result showed that more than fifty percent of nurses were trained but in this study, only twenty-five percent of nurses were trained on IV cannula-related infection prevention.Nurses who received training increase their practice.The Malaysian study, included only inpatient ward nurses, whereas all nurses workings in the hospital were included in this study.Additionally, participants were selected using purposive sampling, whereas this study used simple random sampling.
In a multivariable logistic regression analysis, variables that were significantly associated with the practice of nurses toward IV cannula-related infection prevention were having good knowledge, training on IV cannularelated infection prevention, availability of guidelines, and working ward/ unit.
Nurses who had good knowledge were more likely to perform good practice towards IV cannula-related infection prevention as compared to nurses who had not good knowledge.This finding was supported by studies conducted in India and Egypt [37,46].This might be due to if the nurses have more knowledge of a particular activity they are more skillful in that activity and it increases their confidence to perform the activities.To provide holistic and continuous quality nursing care at every level of service delivery needs adequate knowledge [47].
Nurses who had taken training were more likely good practice towards IV cannula-related infection prevention as compared to nurses who had not trained.This finding was supported by studies conducted in Egypt, and Greek [1,48].The possible explanation for this finding could be the fact that training could upgrade the knowledge and skill of nurses.They would easily understand basic principles and standards of practice and implement them constantly [31].
Nurses working in wards/ units that have availability of guidelines is more likely to increase their good practice as compared nurses working in wards/units that were not availability of guidelines.The possible justification might be due to nurses who have worked in guidelines availability wards/units were more likely to know how to prevent this infection and get updated information which increases their practice of intravenous cannula-related infection prevention interventions [49].
Nurses who worked in the emergency, intensive care unit, pediatrics, and neonatal intensive care unit more likely to perform good practice towards IV cannularelated infection prevention as compared to nurses who worked in the outpatient department.This finding is supported by a study conducted in Italy [28].This might be in those wards/units the procedure is routinely performed.It motivates nurses to know about intravenous cannula-related infection prevention methods also it might be nurses' more exposure to this procedure have a greater chance to know how to prevent IV cannularelated infection prevention from their own mistakes and also their Colleague's [50].
Extensive efforts have been made to minimize the possible limitation of this study.Biases, especially those associated with participants' practices, may exist in selfreported; therefore, participants may overstate their good practices.The cross-sectional nature of this study will make it unable to form a temporal relationship between the outcome and predictor variables.The study is also prone to social desirability bias which could lead to over/ underestimation of the study finding.

Conclusion
The results of this study indicated that nearly half of the nurses had poor knowledge and practice in intravenous cannula-related infection prevention.Having a higher educational level, attending formal training, sex, and working in inpatient wards indicated that positive association with good knowledge.Whereas having good knowledge, attending formal training, having availability of guidelines, and also working in inpatient wards were found to be significantly associated with good practice in intravenous cannula-related infection prevention.
Based on this finding, the Ministry of Health and the Hospital administrators with the collaboration of other stakeholders have to be made to update the knowledge and practice of healthcare workers.Regarding intravenous cannula-related infection prevention activities by providing pre-service or in-service training, preparing and informing intravenous cannula-related infection prevention guidelines, developing educational level of nurses, and inpatient ward nurses better to share their knowledge and practice with outpatient department nurses in order to improve their knowledge and practice towards intravenous cannula-related infection prevention.
Researcher will be done further researches and also using qualitative research methods to assess practice of nurses towards intravenous cannula-related infection prevention.

Fig. 1
Fig. 1 Schematic presentation of sampling procedure of nurses' knowledge, practice, and associated factors on intravenous cannula related infection prevention in Northwest, Amhara regional state comprehensive specialized hospitals.Where; UoGCSH University of Gonder comprehensive Specialized Hospital.TGCSH Tibebe Gione Comprehensive Specialized Hospital.FHCSH Felege Hiwote comprehensive Specialized Hospital.DTCSH Debre Tabor comprehensive Specialized Hospital.DMCSH Debre Markos comprehensive Specialized Hospital.n total calculated sample size N total population for all hospitals, Ni total population from each hospital, ni sample size from each hospital.Sur.W Surgical Ward Med.W Medical Ward.Emer.W Emergency Ward ICU Intensive care unit.Peda.W Pediatrics Ward OPD Out Patient Department.Opta.C Ophthalmic clinic times more likely knowledgeable as compared to nurses who had not trained [AOR = 2.16, 95% CI (1.31, 3.57)].Being male nurses 3.29 times more likely knowledgeable about IV cannula-related infection prevention as compared to female nurses [AOR = 3.29, 95% CI (2.14, 5.06)].

Table 1
Socio-demographic characteristics of study participants working at Northwest Amhara regional state comprehensive specialized hospitals, 2022 (n=412)

Table 2
Institutional and other related factors about a study participant in Northwest Amhara regional state comprehensive specialized hospitals, 2022 (n=412)

Table 3
Nurses' knowledge on intravenous cannula-related infection prevention working in Northwest Amhara regional state comprehensive specialized hospitals, 2022 (n=412)

Table 4
Nurses' practice on intravenous cannula-related infection prevention working in Northwest Amhara regional state comprehensive specialized hospitals, 2022 (n=412

Table 5
Bivariable and Multivariable analysis of factors associated with nurses' knowledge towards prevention of intravenous cannularelated infection, Northwest Amhara regional state comprehensive specialized hospitals, 2022 (n=412) * Statistical significance at p value < 0.05 and CI didn't include 1 with AOR, (*) variables which are significantly associated, 1 = for reference Category, Avail= Availability

Table 6
Bivariable and Multivariable analysis of factors associated with nurses' practice towards prevention of intravenous-cannula related infection, Northwest Amhara regional state comprehensive specialized hospitals, 2022 (n=412)